Provider Demographics
NPI:1336663111
Name:ARENDS, KELLY THOMAS (MED, LAT, ATC,)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:THOMAS
Last Name:ARENDS
Suffix:
Gender:M
Credentials:MED, LAT, ATC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 CENTRAL METHODIST SQ
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:MO
Mailing Address - Zip Code:65248-1104
Mailing Address - Country:US
Mailing Address - Phone:660-248-6978
Mailing Address - Fax:660-248-6381
Practice Address - Street 1:501 WESTMINSTER AVE
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251-1299
Practice Address - Country:US
Practice Address - Phone:573-592-5332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170101162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer